Child/Young Person details:
Full Name / Is the child also known by any other name?Male Female / Date of Birth
Address
Post Code / Other address information (if they live at more than one address
Post Code
Contact Tel no: / Contact Tel no:
EthnicityWhite BritishAfricanBangladeshiCaribbeanChineseIndianPakistaniWhite IrishWhite and Black CaribbeanWhite and Black AfricanWhite an AsianTraveller of Irish HeritageGypsy/RomaAny other White backgroundAny other Black backgroundAny other Asian backgroundAny other Mixed backgroundAny other Ethnic GroupNot given If other please specify / Date of completion:
Have you checked with the Integrated Working Team whether an Early Help Assessment and plan is already in place?
If not, ring 01204 331392/4 to find out and get contact details of the current Lead Professional.
ServiceDetails:
Person completing this form (Lead Professional)Full Name
Job Title / Agency / Address / Tel:
Email:
Mob:
Reason for completing the Early Help assessment and Action Plan:
Does the child or their parent(s) have any special requirements such as disability or language/communication issues? (If so, please explain clearly)
People present at the assessment/Child Action Meeting:
Parent/Carer details
Name
Relationship to child
Address if different to above Contact telephone number / Parent / Parent
The Assessment
Provide a full + relevant picture here about the child and family. Record what services need to know to be able to deliver a service without the family having to repeat information already known. More guidance on completing the assessment + possible discussion questions for each heading are can be found at:
Please ensure that the views of parent (s) and the child (if old enough) are included in this section as well as professional information.Development of the child or young person
General Health
Physical Development
Speech, language and communication
Emotional and social development
Behavioural development
Identity, including self-image, social presentation and self-esteem
Family and social relationships
Self-care skills and independence
Understanding, reasoning, problem solving in learning
Participation in learning, education and employment
Progress and achievement in learning
Learning - Aspirations
Parents and Carers
Basic Care, ensuring safety and protection
Emotional warmth and stability
Guidance, boundaries and stimulation
Family and Environment
Family history, functioning and well-being
Wider Family (details of siblings, other significant adults, if a child lives/visits with another family member )
Housing, employment and financial considerations
Social and community elements and resources
Early Help Action Plan
Who else is already involved?
Education setting: / Name of Main Contact: / Contact details:Is the child receiving any additional support from the education setting?
Service Name: / Worker’s name: / Contact details:
What are the goals the service is working to achieve and what progress has been made so far?
Service Name: / Worker’s name: / Contact details:
What are the goals the service is working to achieve and what progress has been made so far?
Service Name: / Worker’s name: / Contact details:
What are the goals the service is working to achieve and what progress has been made so far?
Service Name: / Worker’s name: / Contact details:
What are the goals the service is working to achieve and what progress has been made so far?
Service Name: / Worker’s name: / Contact details:
What are the goals the service is working to achieve and what progress has been made so far?
Service Name: / Worker’s name: / Contact details:
What are the goals the service is working to achieve and what progress has been made so far?
GP name: / GP Practice: / Contact details:
Summary of assessment:
What’s going well?What does the action plan need to address?
How we will know how things have improved:
In addition to continuing the above actions, the following new actions are needed:
Goal / Action / Who is requested to undertake this action? / Timescale?Is a Child Action Meeting needed to review this plan? Yes No
The action plan will be reviewed and updated on:
Consent section
Before sharing this information with other services, consent must be sought and agreed. Please keep a signed copy in your records. (This can be a scanned copy).
Record electronically on the form the name of the personwho signed it, the date it was signed and complete a statement in the Additional notes section that a signed copy is kept in your records.
Consent statement to be completed by parent and/or child (if they are old enough)
I understand and agree with the information that is recorded on this form. I understand and agree that it will be stored and used for the purpose of providing services.I have had the reasons for information sharing explained to me and I understand those reasons.
I agree that the agencies who need to receive this information are:(please list)
Parent/Carer: / Name: / Date:
Parent/Carer: / Name: / Date:
Child/Young Person: / Name: / Date:
Practitioner: / Name: / Date:
Any Other Additional Notes or Comments:
When the consent statement has been signed, and agreement gained to share the information, a copy should be sent to the services named above.
A copy should be provided to the family.
For quality assurance and reporting processes, please also ensure a copy of this form is sent securely to:
or
Integrated Working (IW) Team
Castle Hill Centre,
Ground Floor,
Castleton Street,
Bolton
BL2 2JW
The IW team does not forward copies on to other services.
If you need any help or support in completing this form then please access the guidance at: or contact the Integrated Working team on 01204 331394 or via email to:
Reviewing the Plan
The Action Plan you have just agreed should be reviewed in 8 – 10 weeks’ time, to ensure that progress has been made and to identify any further actions/support needed. Please use an additional Early Help Review Form for each review you undertake. The form can be found on the Early Help page of the website (as above).